Lectura critica


Nombre: Lilieth Veyanira Hernández
Dra. Alejandra Larios
Caries patterns in primary dentition
in 3- to 5-year-old children. Medellín, Colombia
Patrones de caries en la dentición primaria de
niños de 3 a 5 años de edad. Medellín, Colombia
Gloria Matilde Escobar Paucar1, Blanca Susana Ramírez Puerta2, Luis Gonzalo Álvarez Sánchez3
Master in Public Health. School of Dentistry, Universidad de Antioquia. E-mail: [email protected],
[email protected] 2 Master in Epidemiology. School of Dentistry, Universidad de Antioquia. E-mail: [email protected],
[email protected]
3
Master in Epidemiology. School of Dentistry, Universidad de Antioquia. E-mail: [email protected], [email protected]
1
ABSTRACT
Key Words: dental
caries,
preschooler, early
childhood caries,
primary dentition
Introduction: early childhood caries (ECC) is a public health problem. Recognizing caries patterns in affected
children can help improve oral health programs focused on the preschool population. The aim of this study was
to identify caries patterns in 3- to 5-year-old children in a low to middle-low socioeconomic area. Methods: a
calibrated dentist recorded caries lesions using ICDAS criteria in 548 children attending four day-care centers in
a low to middle-low socioeconomic area. ECC and S-ECC prevalence and the proportion of affected
teeth/surfaces by lesion type for homologous teeth were calculated. Results: a total of 419 (76.5%) and 238
(43.4%) children had ECC and S-ECC, respectively. Average dmft was 3.7±3.7 and average affected surfaces were
5.8±7.7. Occlusal surfaces showed the highest caries experience, varying from 17.7% to 36.1%, showing statistical
significance when compared to other molar surfaces. The upper smooth anterior surfaces were affected from
0.2% to 17.2%, while lower smooth anterior surfaces showed values between 0.0% and 6.8%. The percentage of
dental caries experience in second molars varies from 37.1% to 42%, while in lower central and lateral incisors
the values range from 1.8% to 4.6%. Conclusion: the specific caries pattern in preschool children with high
prevalent ECC from a middle-low-income area indicate the need to design programs aimed at detecting early
sings of dental caries in specific locations, as well as disease control strategies.
RESUMEN
Introducción: la caries de la infancia temprana (CIT) es un problema de salud pública. Identificar el patrón de
caries en los niños afectados puede ser útil para mejorar los programas de salud bucal centrados en la población
preescolar. El objetivo del presente estudio consistió en identificar patrones de caries en niños de 3 a 5 años de
edad en un área socioeconómica baja y media-baja. Métodos: un dentista calibrado registró lesiones de caries
utilizando criterios ICDAS en 548 niños que asisten a cuatro guarderías de un área socioeconómica baja y mediabaja. Se calculó la prevalencia de CIT y CIT-S (severa) y la proporción de dientes/superficies afectados por tipo de
lesión para dientes homólogos. Resultados: hubo un total de 419 (76,5%) CIT y 238 (43,4%) CIT-S. El cpod
promedio fue de 3,7 ± 3,7 y el promedio de superficies afectadas fue de 5,8 ± 7,7. Las superficies oclusales
presentaron la mayor experiencia de caries, en un rango de entre 17,7% y 36,1%, lo que indica una significación
estadística en comparación con otras superficies molares. Las superficies lisas anteriores superiores se vieron
Palabras clave:
afectadas entre el 0,2% y el 17,2%, mientras que las superficies lisas anteriores inferiores mostraron valores entre
caries dental,
0,0% y 6,8%. El porcentaje de experiencia de caries dental en los segundos molares varía del 37,1% al 42%,
preescolar, caries de mientras que en los incisivos centrales y laterales inferiores oscila entre el 1,8% y el 4,6%. Conclusión: el patrón
la infancia
específico de caries en niños en edad preescolar con alta prevalencia de CIT en un área de ingresos medios-bajos
temprana, dentición indica la necesidad de diseñar programas que incluyan acciones destinadas a detectar caries dentales en lugares
primaria
específicos, así como estrategias para el control de la enfermedad.
Submitted: March 15/2019 - Accepted: May 28/2019
How to quote this article: Escobar-Paucar GM, Ramírez-Puerta BS, Álvarez-Sánchez LG. Caries patterns in
primary dentition in 3- to 5-year-old children. Medellín, Colombia. Rev Fac Odontol Univ
Antioq. 2019; 31(1-2): 47-56. DOI: http://dx.doi.org/10.17533/udea.rfo.v31n1-2a4
48
Revista Facultad de Odontología Universidad de Antioquia - Vol. 31 N.o 1-2 - Second semester, 2019 / ISSN 0121-246X / ISSNe 2145-7670
Caries patterns in primary dentition in 3- to 5-year-old children. Medellín, Colombia
INTRODUCTION
Dental caries is one of the most prevalent
chronic conditions in industrialized and
nonindustrialized countries. Its onset before
six years of age (Early Childhood Caries, ECC)
is recognized as a public health problem with
oral consequences and impacts on children’s
and their families’ quality of life.1,2,3 While
there is evidence of an overall decline in the
number and severity of carious lesions, time
trends differ among countries. Preschoolers
are the group that least benefits from
measures intended to improve oral health,
and the disease shows a skewed distribution
in children living in the same area. These
findings suggest that more actions are needed
to deal with oral health
inequalities.4,5
In Colombia, the latest National Oral Health
Survey showed that dental caries affects 83%
of three-year-old children, reaching 88.8% in
five-year-old children when both cavitated
and non-cavitated lesions are included.6
Moreover, dental caries, as one of the most
prevalent chronic conditions in spite of the
intensive preventive programs implemented
in many countries, illustrates the limitations of
such programs to deal with the disease
burden and highlights the importance of
additional information to design programs
aimed at the early childhood according to the
available evidence on control strategies.7
The studies on carious lesions distribution
show that it is not uniform, suggesting the lack
of random effect of contributing factors, as
well as the presence of specific patterns in
terms of teeth position and characteristics.
Some authors suggest that there is no real
right/left symmetry, although certain groups
of teeth show similar susceptibility to lesion
development.8 Caries patterns may vary in
primary dentition, with the upper central
incisors being the most affected teeth until
the age of three,3,9 and second molar occlusal
surfaces the most affected in five-year-old
children.4,10,11 Another study showed no
agerelated pattern, with the second molar
being the most affected in preschool
children.12
Recognizing specific caries patterns within a
given population can be useful for oral health
programs and warns clinicians about the early
detection in preschool children. As noninvasive therapies have proven to be effective
for caries prevention and for the management
of initial lesions,13 caries patterns should be an
important tool in changing invasive
interventions into a more preventive, caries
control approach, leading to better results for
both individuals and populations.14
The aim of this study was to identify caries
patterns in children aged 3 to 5 years living in
a low to middle-low socioeconomic area in
Medellin, Colombia, based on the ICDAS
detection system, which records lesions at
different severity stages.15
METHODS
A cross-sectional descriptive study was
performed in children under six, attending
preschool day care institutions located in a
middle-low socioeconomic neighborhood
from the northeastern area of Medellin. The
study was carried out in four out of twelve
private institutions with government funding
and was approved by the Ethics Committee of
the Universidad de Antioquia School of
Dentistry. All children aged three, four and
five years attending selected infant day-care
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49
centers were examined, prior presentation of
an informed consent by the legal guardians of
all participants in the study. A total of 548
available records from participants aged three
to five were included for data processing and
results.
Dental status was recorded according to
International
Caries
Detection
and
16
Assessment System (ICDAS), including the
modification suggested for this type of studies
(ICDAS epi), merging ICDAS lesions level 1 with
those of level 2.17 A calibrated dentist
(intraexaminer Kappa 0.77 and interexaminer
0.71) registered caries lesions. Prior to clinical
examination, an adult brushed each child’s
teeth; cotton pellets were used to isolate the
examination area, and dental surfaces were
dried with gauze and air. Visual inspection of
all present tooth surfaces was carried out, and
a probe (Ball-tip Screening) was used when
needed.
years of age. The severe form (S-ECC) is
identified in the presence of any sign of caries
on smooth surfaces in children under 3 years,
when one or more smooth surfaces of the
upper anterior primary teeth have cavitated
lesions, are filled or lost due to caries, or when
the number of carious, filled or lost surfaces
by caries is ≥4 at 3 years, ≥5 at 4 years, and
≥6 at 5 years of age.18
The collected data were analyzed in the IBMSPSS® program, version 23.0. The percentages
of affected teeth and tooth surfaces were
estimated for the whole group and by single
age, using frequency distribution. The
percentage of surfaces affected by
homologous teeth was calculated and
differences were analyzed with the Epidat 3.1
software, using either the Chi square test or
the Fisher’s exact test.
RESULTS
The presence of early childhood caries (ECC)
Table 1. Distribution of children with ECC and S-ECC, mean dmft (SD) and mean dmfs (SD) by age
ECC*
S-ECC**
dmft†
dmfs‡
Age
n°
%
CI
n°
%
CI
Mean (SD)
CI
Mean (SD)
CI
3 year-old (n=173)
120
69.4
62.5; 76.3
70
40.5
33.2; 47.8
3.0 (3.4)
2.5; 3.5
4.3 (6.1)
3.4; 5.2
4 year-old (n=216)
172
79.6
74.2; 85.0
101
46.8
40.1; 53.5
4.1 (4.0)
3.6; 4.6
6.3 (7.3)
5.3; 7.3
5 year-old (n=159)
127
79.9
73.7; 86.1
67
42.1
34.4; 49.7
4.0 (3.9)
3.4; 4.6
6.8 (9.5)
5.3; 8.3
Total (n=548)
419
76.5
72.9; 80.1
238
43.4
39.3; 47.5
3.7 (3.7)
3.4; 4.0
5.8 (7.7)
5.2; 6.4
*: Early childhood caries. **: Severe early childhood caries. CI: Confidence Interval 95% †: decay, missing and filled teeth index. ‡: decay, missing
and filled surfaces index
Source: by the authors
and severe early childhood caries (S-ECC) was
recorded according to the guidelines set forth
by the American Academy of Pediatric
Dentistry. ECC is defined as the presence of
one or more primary teeth surfaces with
caries (either cavitated or non-cavitated),
filled or missing by caries, in children under six
From a total of 548 children evaluated, 76.5%
showed early childhood caries (ECC) and
43.4% had severe early childhood caries (SECC). In terms of dmft (including noncavitated lesions), each child had an average
of 3.7±3.7 teeth and 5.8±7.7 surfaces affected
by dental caries, varying from 3.0±3.4 and
50 Revista Facultad de Odontología Universidad de Antioquia - Vol. 31 N.o 1-2 - Second semester, 2019 / ISSN 0121-246X / ISSNe 2145-7670
Caries patterns in primary dentition in 3- to 5-year-old children. Medellín, Colombia
4.3±6.1 in 3-year-old children to 4.0±3.9 and
6.8±9.5 in 5-year-old children (Table 1).
A total of 47,711 surfaces were examined,
with the occlusal surface showing the highest
values of caries lesions experience, varying
from 17.7% to 36.1%. These were followed by
upper smooth anterior surfaces affected in
0.2% to 17.2%. The lower smooth anterior
surfaces showed the lowest values, from 0.0
to 6.8%, and as observed in upper anterior
teeth, the lingual surfaces were the least
affected. The individual teeth with the highest
proportion of dental caries experience were
55 (42%), 75 (40%), 85 (38.3%) and 65 (37.1%);
the lowest experience was found in 71 (1.8%),
81 (2.2%), 72 (2.9%) and 82 (4.6%). The
proportions of dental caries experience by
tooth and tooth surface are shown in Figure 1.
a) All children (n= 548)
b) Three-year-old children (n=173)
c) Four-year-old children (n=216)
d) Five-year-old children (n=159)
Figure 1. Dental caries experience (% affected) in primary teeth for 3- to 5-year-old children, by tooth and tooth surface levels.
Source: by the authors
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51
The analysis of caries experience by tooth type
showed that 39.5% of the upper second
molars and 39.2% of the lower molars were
affected, followed by upper first molars (29%)
and upper central incisors (23.2%). The lowest
values were observed in lower central and
lateral incisors, with 2.0% and 3.8%
respectively (Figure 2).
incisors, lesions appear in a similar proportion
in the bucal, mesial and lingual surfaces.
Figure 2 illustrates the distribution of caries
presence per tooth surface in homologous
teeth, showing predominance of occlusal
lesions in primary molars and buccal surfaces
in lateral upper incisors. In the upper central
a) All children
b) Three-year-old children
c) Four-year-old children
d) Five-year-old children
Figure 2. Distribution of affected teeth surfaces per tooth type (% with caries experience).
52 Revista Facultad de Odontología Universidad de Antioquia - Vol. 31 N.o 1-2 - Second semester, 2019 / ISSN 0121-246X / ISSNe 2145-7670
Source: by the authors
Caries patterns in primary dentition in 3- to 5-year-old children. Medellín, Colombia
Table 2 shows the caries pattern for each
homologous tooth in terms of the most
affected surfaces, comparing each surface,
referred to as “caries attack rates” by Gizani et
al.19 Each individual surface was compared
with others by Chi square test or Fisher’s exact
test. Statistical significance was found
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Table 2. Comparison of caries experience among homologous teeth surfaces (D: distal, B: labial or facial, M: mesial, L: lingual, O:
occlusal)
Age
3 to 5
years
3 years
4 years
5 years
Tooth type
Caries pattern
D-B
D-M
D-L
B-M
B-L
51/61
B>M>L>D
***
***
***
D-O
ns
ns
*
M-O
L-O
71/81
B>M>L>D
***
ns
ns
**
***
ns
52/62
B>M>L>D
*
*
***
***
***
ns
72/82
B>M>L>D
***
**
ns
*
***
*
53/63
B>L>D>M
***
*
ns
***
***
**
73/83
B>M>L>D
***
*
ns
***
***
ns
54/64
O>B>D>M>L
ns
ns
ns
***
ns
*
***
ns
***
***
74/84
O>B>L>D>M
***
**
ns
***
***
***
***
**
***
***
55/65
O>L>B>M>D
***
ns
***
***
***
***
***
***
***
***
75/85
O>B>L>M>D
***
ns
***
***
***
***
***
***
***
***
51/61
B>M>L>D
***
*
ns
ns
*
ns
71/81
B
**
†
†
*
*
†
52/62
B>M>L>D
***
***
*
ns
*
ns
72/82
B>M
**
ns
†
ns
**
ns
53/63
B>L
***
†
ns
***
**
ns
73/83
B>M
***
ns
†
**
***
ns
54/64
O>B>M>L>D
***
ns
ns
***
ns
ns
***
ns
***
***
74/84
O>B>L>D>M
***
ns
ns
***
***
***
**
ns
***
***
55/65
O>L>B>D>M
ns
ns
***
***
*
***
***
***
***
***
75/85
O>B>L>D>M
***
ns
ns
***
***
***
*
*
***
***
51/61
B=M>L>D
***
***
***
ns
ns
ns
71/81
B>M>L=D
*
ns
ns
ns
ns
ns
52/62
B>M>L>D
***
***
**
***
***
ns
72/82
B>M>L=D
***
*
ns
ns
***
ns
53/63
B>L>D
***
ns
ns
***
***
ns
73/83
B>M>L>D
***
ns
ns
***
***
ns
54/64
O>B>M>D>L
ns
ns
ns
***
ns
ns
***
ns
***
***
74/84
O>B>D>L>M
***
ns
ns
***
***
***
***
ns
***
***
55/65
O>L>B>D>M
**
ns
***
***
***
***
***
***
***
***
75/85
O>B>L>M>D
***
ns
***
***
***
***
*
**
***
***
51/61
B=L>M>D
*
ns
*
ns
ns
ns
71/81
B>L>M
*
ns
ns
ns
ns
ns
52/62
B>L>M>D
***
**
**
*
*
ns
72/82
B>M>L>D
*
ns
ns
ns
ns
ns
53/63
B>L>D>M
***
ns
ns
***
***
ns
73/83
B>M>L
***
ns
ns
***
***
ns
54/64
O>D>B>L>M
ns
ns
ns
ns
ns
***
***
***
B-O
***
M-L
ns
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74/84
O>B>L>D>M
*
*
ns
***
***
ns
***
*
***
***
55/65
O>L>B>M>D
ns
ns
***
***
ns
***
***
***
***
***
Caries patterns in primary dentition in 3- to 5-year-old children. Medellín, Colombia
when the occlusal surface is compared with
the rest of upper and lower molar surfaces. It
was also found in anterior teeth, when the
labial or facial surfaces were compared to
lingual surfaces, with the exception of the
upper central incisors.
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55
DISCUSSION
The present study shows a specific pattern of
dental caries in preschool children living in an
urban area, belonging to a high prevalent
group where severe forms of Early Childhood
Caries affects more than 40% of examined
children. Even though caries lesions are
present in all teeth, with the exception of a
few surfaces from anterior lower teeth in the
entire group, distribution is not uniform by
tooth type, showing that caries lesions are not
evenly distributed.
The most affected teeth in the three- to fiveyear-old group were second molars, followed
by first lower molars and upper central
incisors. These findings are similar to those by
Sowole et al12 and Gizzani et al19 in terms of
anterior primary teeth being less affected
than posterior teeth, regardless of caries
levels. But there is a difference with Gizzani et
al, who report first lower molar as the most
affected posterior teeth, followed by central
incisor in a group of 2-6-years-old; this also
differs from the findings by Ferro et al,11 who
reported that mandibular molars were the
most commonly affected teeth in a sample of
five-year-old children.
The variations among studies could be
explained as an effect of grouping children by
ages, as Vanobbergen et al14 reports upper
central incisors showing the highest caries
experience prevalence in the 3-yearold group;
trend changing for the 5- and 7-year-old kids,
in which the highest caries prevalence level
was observed in the mandibular molars. There
could also be population differences. As
Sowole et al12 report, it appears to be a nonsignificant age-related caries distribution
pattern, based on clinical examinations in
preschool children, concluding that neither
rampant caries nor simple caries prevalence
appear to be age dependent. Do1 states that
there are significant variations in levels of
caries experience as well as in time-trends of
caries experience among populations with
different levels of social and economic
development.
In this study, the most affected teeth among
3-year-old children were the upper second
molars and lower second molars, followed by
first lower molars, first upper molars and
central upper incisors. For the 4-yearold
children, second molars remain the most
affected teeth, followed by first lower molars,
but upper central incisors show higher
proportions of caries lesions than upper first
molars. By age 5, second lower molars appear
as the most affected tooth type, followed by
second upper molars, first lower molars, first
upper molars and upper central incisors.
As in other studies, caries prevalence
increases with age, showing a cumulative
effect from 3 to 5 years, but no conclusions
could be stated about lesion progression and
changing patterns by age as these are crosssectional
data.
Cohort
studies
or
crosssectional studies including larger
samples could provide valuable information
on specific patterns by age, guiding clinicians
and program leaders in the formulation of
regular screenings for each age group.
In analyzing available data by tooth surface,
not all teeth show the same susceptibility. The
lingual anterior surfaces were the least
frequently affected in the anterior region, and
the occlusal were the most affected molar
teeth surfaces. These findings are similar to
those reported in other studies dealing with
either low caries or high caries experience
populations.9,14,19,20 While some authors refer
to specific surface involvement as “caries
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Caries patterns in primary dentition in 3- to 5-year-old children. Medellín, Colombia
attack rates”,19 there is no evidence of time
sequence of lesions, but this is an important
information about the distribution of caries
presence according to tooth surface by tooth
type. For all posterior teeth, regardless of age
groups, the most affected surfaces are the
occlusal ones, showing statistically significant
differences between the occlusal surface and
the others, as compared individually. For
anterior teeth, the most affected surface is
the labial or facial, but consistent statistically
significant differences are only observed
between buccal and lingual surfaces. A
limitation of the present study is that it did not
evaluate symmetry (the spatial distribution
between the right and left homologous teeth)
as showed by Vanobbergen et al14 because the
total number of teeth in each group would not
be enough.
While
information
about
occlusal
susceptibility is highly relevant in terms of
screening focus, treatment needs and
preventive strategies, it could be inadvisable
to wait until molar eruption—occurring later
during early childhood—for risk assessment
and early childhood preventive programs
based on this data only. Dental teams and
children’s health providers are increasingly
aware of the need of implementing
preventive measures from the first year of life.
Non-dental healthcare providers could be of
great help by identifying any single lesion,
irrespective of its location, and referring the
child for treatment and establishment of a
dental home.21,22 An oral check-up after the
first tooth eruption should be integrated into
the existing health programs like vaccinations
and general medical check-ups.2
Many attempts are made to deal with caries
burden. For Seiham,23 caries prevention is
preferable to treatment, but the high levels of
caries worldwide suggest that current
preventive approaches are not working. As
stated in Brussels by the EAPD13 and Pitts et
al,24 non-invasive therapies have proven to be
effective for caries prevention and the
management of pre-cavitated carious lesions.
Knowing the most commonly involved teeth
and surfaces in a specific population is key to
guide dental screenings aimed to identify
early signs and to promote adequate oral
hygiene practices and fluoride use to stop
lesions, according to the caries control
concept.25
CONCLUSION
A group of children living in a high prevalent
ECC middle-low-income community shows
specific patterns of caries lesion distribution,
with primary molars being the most
commonly affected, especially the occlusal
surfaces, followed by the upper central
incisors. These data are useful for programs
aimed at families and communities to detect
early sings of dental caries, and to guide
dental care services in timely diagnosis and
lesion progression strategies.
CONFLICT OF INTEREST
The authors declare that they have no conflict
of interest.
CORRESPONDING AUTHOR
Gloria Matilde Escobar Paucar
Universidad de Antioquia (+57)
219 6772
[email protected],
Revista Facultad de Odontología Universidad de Antioquia - Vol. 31 N.o 1-2 - Second semester, 2019 / ISSN 0121-246X / ISSNe 2145-7670
57
[email protected]
Calle 64 #52-59
Medellín. Colombia
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and distribution by tooth surfaces in primary molars in the pre-school child population of Lodz, Poland. Oral
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Evaluando detenidamente el articulo de Patrones de caries en
detención primaria en niños de 3 a 5 años. Medellin, Colombia,
hemos recurrido a hacer su evaluación apoyados de las 5
secciones proporcionadas por STROBE; el cual, de una forma
rápida, fácil y segura nos permitirá saber si la información que
encontramos nos ofrece ayuda eficaz para satisfacer nuestras
incognitas y para la ayuda y beneficio de nuestros pacientes.
Partiendo desde su primera sección que es la evaluación de "El
titulo con resumen", según lo observado en este articulo
podremos decir que dentro de esta parte nos ofrece una
pequeña pestaña de asemejacion en cuanto a su información
proporcionada procedentemente, su titulo es claramente
indicativo con respecto al contenido del articulo, a demás de ello
sigue un margen coherente en cuanto a su desarrollo sin perder
la línea con la que este ha iniciado, nos proporciona información
de sus autores; como sus datos personales, establece palabras
claves donde nos hace saber el lado de elocuencia y esteticidad
con el cual estará centrado dicho desarrollo de la información.
En el resumen general nos marca escencialmente los puntos que
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se desglosara la información y en ello una breve definición en
cuanto a lo que sera basado cada punto, asi mismo, claramente
nos hace visual su objetivo a lograr.
En su sección dos que es la "Introduccion", podemos asegurar la
aclaración proporciona en sus escritos, en este punto comienza
hablando un poco del impacto de las caries dentales y sus
distintos métodos causales, para luego centrarse en un balance
aproximado de afecciones a niños de distintas edades y por
ultimo hace enfacis a su objetivo a lograr, el cual es clave para
sus resultados a obtener durante la indagación del trabajo,
permitiéndonos contemplar de una manera global la validez
externa que presenta este articulo.
La sección numero tres que son los "Materiales y Metodos", en
esta parte; hacen la explicación de los métodos que utilizaron
para poder hacer la evalucion del caso y poder obtener
resultado verídicos y de suma relevancia, por ejemplo su técnica
fue de encuestas, exámenes clínicos, el cepillado por parte de un
adulto a cada niño para luego realizar las inspecciones visuales
de todas las superficies dentales acompañado de pequeños
objetos estratégicos en ello, de igual manera hacen la explicación
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de las variables que estudiaron; como la presencia de caries de
la primera infancia y caries de la primera infancia severa, la
participación de la población fue fundamental para su
realización ya que contaron con una cantidad disponible de
participantes de 548 niños de preescolar en uno de los barrios
de esta ciudad.
Los "Resultados", son la sección cuarta, aca nos regalan una
escision de cuadros y graficas ordenadas en un orden lógico de
las edades de los niños evaluados y ancladas a ellas una
aclaración promediada de los resultados valorados y obtenidos,
de igual manera, nos hacen posible el comtemplar las variables
en investigación.
La ultima sección es la "Discusion del estudio", como
anteriormente expresamos, este trabajo desde el inicio;
partiendo del titulo del articulo recorre un hilo de coherencia
por todo su desarrollo para lograr ofrecernos una información
benéfica y con un alto grado de importancia, la discusión con los
resultados deben compartir una relación muy apelativa, puesto
que de los resultados proporcionados es del cual daremos como
respuesta final lo que es la discusión, en ella se retoman puntos
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Caries patterns in primary dentition in 3- to 5-year-old children. Medellín, Colombia
geneales pero los mas impotantes para terminar de esclarecer
el punto final del trabajo valorado y asi brindar una conclusión
fundamental y final de lo evaluado, en este articulo, en esta
sección, al momento de su análisis, lectura y visualización
podremos notar los altos grados de apoyo y relación que
presenta con los resultados para poder llegar al efecto final de
todo el proceso de evalucion, podemos consolidar cada punto
expuesto como una cohesion muy buena donde a los lectores nos
permite seguir un margen muy lógico desde su inicio de
investigación hasta su etapa final de resultado.
Por ultimo nos dejan una pequeña conclusión globalmente
abarcadora y explícitamente importante donde nos hace saber
que se ha logrado obtener y dar soluciones de salida al objetivo
propuesto; por tal razón la proporcion final es el brindar de una
amplia bibliografía para continuar indagando y hacernos saber
cuales fueron sus fuentes bases durante su escrutamiento.
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